Provider Demographics
NPI:1295717601
Name:LEBANON MEDICAL CENTER, INC
Entity type:Organization
Organization Name:LEBANON MEDICAL CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHUMATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-228-1666
Mailing Address - Street 1:7661 BROOKFARM CT
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-7027
Mailing Address - Country:US
Mailing Address - Phone:513-398-7376
Mailing Address - Fax:
Practice Address - Street 1:990 BELVEDERE DR STE A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-2890
Practice Address - Country:US
Practice Address - Phone:513-228-1666
Practice Address - Fax:513-228-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-20
Last Update Date:2012-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207R00000X207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00219908OtherRAILROAD MEDICARE
OH2545857Medicaid
OH378156491001OtherMEDICAL MUTUAL OF OHIO
OH378156495-00OtherOHIO BWC
OH378156491001OtherMEDICAL MUTUAL OF OHIO
OHP00219908OtherRAILROAD MEDICARE